Provider Demographics
NPI:1104238153
Name:MURRAY, MATTHEW JACOB (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JACOB
Last Name:MURRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:MURRAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:12330 ASHLEY DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2737
Practice Address - Country:US
Practice Address - Phone:228-831-1572
Practice Address - Fax:228-831-1218
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS29161207R00000X
SD55554207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ028297Medicaid